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Encopresis is a term used to describe
children involuntarily or intentionally
passing feces in unacceptable locations
(for example, in undergarments or on
the floor) a minimum of one time per
month for three months in a child over
four years of age chronologically and/or
developmentally (First & Tasman, 2004).
This condition rarely occurs in isolation
but more commonly accompanies
chronic constipation with retention,
resulting in large, infrequent stools
passed less than three times per week,
Identified Causes of
Chronic Childhood Stool
Retention and Encopresis
The causes of chronic childhood
stool retention with encopresis can usually be traced back to an event or events
occurring during the early toilet training
period in a childs life that caused a
painful or unpleasant bowel movement.
Other contributing factors include a)
chronic, early constipation during
infancy, b) low overall muscle tone and
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Symptoms of Encopresis
Early identification of encopresis
by pediatric nurse practitioners leads
to early treatment, which is far more
108
Table 1.
A Summary of Risk Factors for Encopresis
Which Child Develops Encopresis?
Eating diets high in fat and sugar (junk food) and low in fiber.
Not drinking enough water.
Not exercising.
Refusing to use the bathroom, especially public bathrooms.
Having a history of constipation or painful experience during toilet training
(ulcerative colitis or anal fissures). Note 63% of children with encopresis
have a history of painful defecation before 36 months of age (Lewis &
Rudolph, 1997).
Having cognitive delays such as autism or mental retardation.
Having learning disabilities.
Having attention deficit disorders or difficulty focusing.
Having conduct or oppositional disorders.
Having obsessive compulsive disorders.
Having a poor ability to identify physical sensations or symptoms.
Having a neurological impairment such as Spina Bifida or paralysis.
Having a chaotic, unpredictable life.
Suffering from abuse and/or neglect.
Note: Children with encopresis generally have three or more of the above risk factors.
Sources: Borowitz at el., 2003; Cox et al., 2003.
Table 2.
The Pattern of Encopresis
1. Initial withholding.
2. Loose, overflow soiling and release of large stools usually less than once every
5 to 7 days.
3. Eventual soiling of large, infrequent bowel movements, chronic soiling of overflow
and large stools, abdominal pain, and social withdrawal.
4. Loss of control and the ability to feel the desire to pass stool**.
**At this point, parents, foster parents, teachers, siblings, and peers often become frustrated and blaming, wondering why a school-aged child cannot control his or her bowels,
and how could he or she possibly claim he or she did not know he or she had soiled.
Table 3.
Diagnostic and Statistical Manual of Mental Disorders - IV (DSM-IV)
Criteria for Diagnosis of Encopresis
The voluntary or involuntary passage of stools, causing soiling of clothes by a child
over four years of age. Encopresis can be divided into two groups. In the first group,
there is a physiologic basis for the encopresis; in the second group, there seems to
be an emotional basis.
1 Encopresis is frequently associated with constipation and fecal impaction.
2 Other causes may be related to a lack of toilet training or training at too early an
age or an emotional disturbance, such as oppositional defiant disorder or a conduct disorder.
Accidentally or on purpose, the patient repeatedly passes feces into inappropriate places (clothing, the floor).
For at least three months, this has happened at least once per month. The
patient is at least four years old (or the developmental equivalent).
This behavior is not caused solely by substance use (such as laxatives) or
by a general medical condition (except through some mechanism that
involves constipation).
Source: American Psychiatric Association, 2004.
Table 4.
Diagnostic Procedures for Encopresis
History
History of constipation and soiling
History of previous treatment and
outcomes
Family history of constipation or
other bowel conditions
Toilet training response
Family changes or stress
Soiling pattern
Diet
Activity level
History of associated conditions,
including enuresis, behavioral and
emotional problems, abdominal pain,
school absentism
Peer and family relationships
Developmental skills
Academic progress
Physical Examination
Abdominal examination
Developmental screening
Abdominal X-rays
Neurological examination
Rectal examination for fecal impaction
Figure 1.
Holiday-Segar Fluid Requirement Calculation Guidelines
1 to 10 kg* = 100 ml/kg
11 to 20 kg = 1000 ml plus 50 ml/kg for each kg over 10 kg
Over 20 kg = 1500 ml plus 20 ml/kg for each kg over 20 kg
*Note. 1 kg = 2.2 lbs.
For example, a child weighing 60 pounds would need (27 kg = 1500 + (7 x 20 = 140
ml) = 1640 ml, or (1640/29.6*) = 55.4 ounces per day or six to seven 8-ounce glasses of fluid per day.
*Note. 1 ounce = 29.6 ml
Source: Holiday & Segar, 1957.
Therefore, most children, after confirming the absence of a large
impaction, can start their treatment
with educational and behavioral
approaches for the child and parent(s),
with an emphasis on changes in nutrition, behavior management, family
support, and medications aimed at
maintaining soft stools.
Nutritional Changes
Nutritional changes are imperative
to the successful treatment of encopresis. The first and most important step is
to add fiber to the diet at a predictable
time each day. The recommended formula for calculating the amount of
fiber is age in years + 5 = number of grams
of fiber/day (Mason et al., 2004). Dietary
fiber can be obtained through cereals,
whole grain breads, fresh fruits and
vegetables, and developmentally
appropriate nuts. If dietary fiber is not
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Bowel Training
Bowel training is needed to help the
child re-learn bowel control and regain
awareness of a full rectum. This is best
done by having the child sit for 10
minutes on the toilet 20 minutes after
breakfast and again 20 minutes after
dinner. This timing is the most likely
time for the bowels to move. The child
should also drink enough water to elicit urination every two hours. When
urinating, the child should interrupt
the stream two to three times before
the bladder is empty. This exercise
helps strengthen pelvic muscles and
sphincter control
Children respond best to these exercises if explained and compared to an
athlete trying to build muscles to perform his or her sport. Adding small
rewards (such as stickers) and praise is
also helpful.
Behavior Management
Many parents are unsure about
what behavior management techniques are most helpful for these children. Punishment does not work and
tends to increase rather than decrease
Family Support
Although treatment is generally
successful, it can take 6 to 12 months
after treatment is started before a child
regains bowel control and appropriate
elimination behaviors. In the meantime, families must cope with soiled
clothing, fecal smell of their child and
parts of their home, sibling and peer
teasing and rejection, and relapses and
frustration. Family members need
information for understanding, and
support from other parents, health
professionals, and if needed, case
workers. Similar to sleeping problems
of an infant, it is very reassuring for
parents to hear the problem will get
better with specific approaches and
they are not alone in treating this challenging condition. The child needs
continual monitoring to assess coping
skills and to address secondary problems, such as enuresis, lowered selfefficacy or self-esteem in relation to
bowel control and relationship skills,
anger, and/or depression. Pediatric
nurses are key team members to help
parents monitor progress and adjust
treatment plans as needed. Some children need social skills training and
support to re-enter and be successful at
social relationships (Baker et al., 1999).
Medications
Medications used to be the hallmark of treatment for encopresis, with
many of these children being subjected to invasive enemas, suppositories,
and excessive stool softeners. The general belief used to be that the impacted
stool had to be removed through
repeated enemas before treatment
could begin. It is now known that
treating a child with oral stool softeners and/or bran has better results and
prevents a child from embarrassing,
painful, expensive, and invasive enemas. Today, enemas are rarely needed
and generally only needed for those
few children with neurological impairments and/or with severe impactions.
The most commonly used medications
are oral stool softeners, such as
MiraLax or Senokot or mineral oil.
Each of these medications has specific
side effects and should only be used
under the guidance of a health professional and in addition to dietary and
behavioral changes.
Regardless of the approach to treatment, the best outcomes occur when a
team is brought together, including the
child, parents, siblings, teachers, and
health professionals, working together
to develop a plan that is evidence-based
and feasible, and includes ongoing support and monitoring. The leader of this
team needs to follow up with the family weekly until the soiling is rare to
absent; follow up needs to continue
monthly for six months. Relapses can
and do occur, especially if schedules or
living situations change, including
vacations and moves. Because of this
tendency, extra effort to maintain
schedules is needed during times of
transition.
muscle tone (soft muscles). His parents expressed concern that he soiled
his pants about twice per week, and
did not seem to notice when he had
stool in his pants. He also wet the bed
nightly. His parents had tried punishing him, making him wear diapers,
and rewarding him for dry nights and
clean underwear at the end of the day,
but none of these approaches made
any difference. Risk factors for encopresis included:
Male gender.
A delay in toilet training, with
poor parental guidance.
Low muscle tone.
A major move in the middle of toilet training, resulting in inconsistent approaches to toilet training
by parents.
Minimal awareness of body sensations, including pain and the need
to eliminate.
High level of focus on external
environment and learning, and
minimal focus on motor skills.
A physical examination revealed an
alert 8-year-old male, with low muscle
tone and poor coordination for age
(for example, unable to complete finger-nose test or alternating finger test).
His abdominal examination revealed a
distended abdomen, and his rectal
examination revealed hard stool in the
rectal cavity. After a careful evaluation
to make sure the problem was not
caused by any physical conditions, Joel
was put on the following treatment
plan:
Take a quarter teaspoon of bran
once per day at the same time each
day, increasing by a quarter teaspoon every third day until bowel
movements are soft and occurring
once per day.
Increase water consumption to 64
ounces per day.
Eliminate any caffeine and sugary
drinks and high-fat foods from the
diet (for example, soda pop, fast
food hamburgers).
Reduce dairy products to two to
three servings per day.
Reduce intake of bananas, tea, rice,
and apple peelings.
Increase roughage through whole
grains and fresh fruits, vegetables
and nuts.
Increase exercise to a minimum of
one hour per day of bike riding,
skating, running, swimming, or
team sports.
Avoid drinking more than a sip of
fluids after 6:30 p.m. each day.
111
Make bathroom trips with an attempt at having a bowel movement and urinating 20 minutes
after each meal.
Give rewards for dry nights and
clean underwear.
Do bladder exercises with each urination (interrupt stream two to
three times per urination, and wait
up to 20 minutes to urinate after
the first urge).
Take daily multiple vitamins with
calcium.
This plan proved successful after
the first three weeks of treatment.
Relapse occurred due to a change in
diet and routine when school let out
for the summer. At this point, Senekot
was added once per day. Success was
re-established, and Joel has been continent of bowel and bladder for three
years now. He was weaned off the
Senekot after continence was maintained for six months.
Conclusion
Encopresis is a problem that has an
impact on approximately 3% of
school-aged children. In spite of this
prevalence, few studies have effectively
demonstrated consistent and effective
results supporting treatment options
(Bloom et al., 1993; Fishman et al.,
2003). Of those studies published, few
used control designs, most had low
participant numbers, and most
occurred over 15 years ago (McGrath,
& Murphy, 2004). This problem starts
with the withholding of stool and ends
with withholding and soiling beyond
the control of the child. A team,
including the child, parents, pediatric
nurse practitioners and pediatric nurses, teachers, and other professionals as
needed, provides the best support
needed to develop the most effective
treatment plan. The treatment plan
needs to address nutritional changes,
increased activity, bowel training,
behavior management, family support, and medications. Even with the
most effective treatment, children
with encopresis generally take up to six
months or longer to regain bowel control consistently and relapses can occur
during times of change or transition.
Positive outcomes take dedication and
time. These children with encopresis
need understanding, support, and
encouragement to be successful at
learning what to do to reach a milestone that many of us take for granted.
112
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Additional Readings
Clayden, G. (1991). Managing the child with
constipation. Professional Care of
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Cox, D.J., Sutphen, J., Ling, W., Quillian, W., &
Borowitz, S. (1996). Additive benefits of
laxative, toilet training and biofeedback
therapies in the treatment of pediatric
encopresis. Journal of Pediatric
Psychology, 21, 659-670.
Lancioni, G.E., OReilly, M.F., & Basili, G.
(2001). Treating encopresis in people
with intellectual disabilities: A review of
the literature. Journal of Applied
Research in Intellectual Disabilities, 14,
47-63.
Loening-Baucke, V., Miele, E., & Staiano, A.
(2004). Fiber (glucomannan) is beneficial
in the treatment of childhood constipation. Pediatrics, 113(3), e259-e264.
Rockney, R.M., McQuade, W.H., Days, A.L.,
Linn, H.E., & Alario, A.J. (1996). Encopresis treatment outcome: Long-term follow-up of 45 cases. Developmental and
Behavioural Pediatrics, 17, 380-385.
Stark, L.J., Opipari, L.C., Donaldson, D.L.,
Danovsky, M.B., Rasile, D.A., &
DelSanto, A.F. (1997). Evaluation of a
standard protocol for retentive encopresis: A replication. Journal of Pediatric
Psychology, 22, 619-633.
Trahms, C. (1983). Encopresis training booklet
for children [unpublished workbook].
Seattle, WA: University of Washington
Child Development Center.